Pathology: Uterus

Question 1

What is primary amenorrhea? Secondary amenorrhea? What are the potential causes?

Answer 1

• primary: absence of menses by age 16
• secondary: loss of menses for at least 6 months in a patient with otherwise normal menstrual history
• causes: pregnancy!, hypothalamic/pituitary disorder, ovarian disorder, anatomical defects

Question 2

What is Asherman syndrome?

Answer 2

• Asherman syndrome is the acquired loss of the stratum basalis (the regenerative layer of the endometrium)
• it is usually due to overly aggressive dilatation and curettage
• this is a rare anatomical defect that can cause secondary amenorrhea (most anatomical defects are present at birth and therefore result in primary amenorrhea)

Question 3

What usually causes endometritis? What finding characterizes chronic cases?

Answer 3

• endometritis is usually due to retained products of conception following delivery/miscarriage/abortion
• chronic cases are characterized by the presence of plasma cells (although chronic infections are related to lymphocytes, lymphocytes are normally already found in the uterus)

Question 4

What are the main causes of abnormal uterine bleeding (AUB) in children? In early reproductive years (menarche to 20)? From 20 to 40? From 40 on?

Answer 4

• prepuberty: vulvovaginitis, embryonal rhabdomyosarcoma of vagina
• menarche to 20: anovulatory cycles due to excess unopposed estrogen, bleeding diathesis, pregnancy
• 20 to 40: pregnancy, PID, leiomyoma (fibroids), endometriosis, endometrial polyp, medication
• 40 on: perimenopause, endometrial hyperplasia and carcinoma

Question 5

What are endometrial polyps? What are they a common cause of?

Answer 5

• these are benign collections of endometrial tissue
• they do NOT progress to carcinoma
• they are a common cause of AUB in females 20-40

Question 6

What causes endometrial hyperplasia? What do we see on histology? How do patients classically present? What are the risk factors and complications?

Answer 6

• endometrial hyperplasia is due to unopposed estrogen, resulting in a constant proliferative phase of the menstrual cycle
• on histo we would see hyperplasia of the glands relative to the stroma
• patients present with AUB, classically with postmenopausal vaginal bleeding (the excessive proliferation results in sporadic cases of shedding)
• RFs: obesity, PCOS, anovulatory cycles, HRT, early menarche, late menopause, nulliparity
• complications: can develop into endometrial carcinoma, so make sure to take a biopsy to check for the architectural growth (simple or complex) and presence of atypia (typical or atypical)

Question 7

What is the most common gynecological malignancy? How does it present? What are the two pathways of development? What are the major risk factors?

Answer 7

• endometrial carcinoma is the most common gynecological malignancy (followed by ovarian and then by cervical)
• classically presents in a 55-65 year old female with postmenopausal bleeding
• two distinct pathways: hyperplastic (following endometrial hyperplasia; usually seen in 50s) and sporadic (occurs in an atrophic endometrium with no precursor lesions; usually seen in 70s)
• RFs: (same as endometrial hyperplasia) obesity, PCOS, anovulatory cycles, HRT, early menarche, late menopause, nulliparity

Question 8

Which type of endometrial carcinoma contains psammoma bodies? Which other carcinomas contain psammoma bodies?

Answer 8

• the sporadic form of endometrial carcinoma that develops in an atrophic (postmenopausal) uterus without a precursor lesion (AKA without endometrial hyperplasia)
• contains serous (AKA papillary-serous) histology that can calcify and form psammoma bodies
• PSaMMoma bodies: Papillary thyroid carcinoma, Serous endometrial and Serous ovarian carcinoma, Mesothelioma, Meningioma

Question 9

What is endometriosis? Where does it most commonly occur? What is it the most common cause of? What are some complications?

Answer 9

• endometriosis is the presence of functional endometrial tissue outside the uterus (most common site is the ovary, also the pelvis and peritoneum)
• it is the most common cause of secondary dysmenorrhea (pain on period); it is also the most common gynecological disorder in the reproductive age group
• patients can also present with dyschezia (suggests involvement of the pouch of Douglas), and dyspareunia
• complications: infertility, ectopic pregnancy, carcinoma at the site of involvement (especially with the ovaries)
• (involvement of the ovaries leads to formation of chocolate ovarian cysts)

Question 10

What is adenomyosis? What causes it?

Answer 10

• adenomyosis is essentially endometriosis within the myometrium
• this is caused by hyperplasia of the stratum basalis layer of the endometrium into the myometrium
• in adenomyomis, the uterus is uniformly enlarged (in endometriosis, the uterus is normal)

Question 11

What is a fibroid? Which age does it most commonly affect?

Answer 11

• a fibroid is a leiomyoma (a benign growth of the smooth muscle of the myometrium)
• they are the most common tumor in females!
• peak occurrence at 20-40 (a common cause of AUB in this age group, but are usually asymptomatic)
• leiomyomas do NOT progress to leiomyosarcomas

Question 12

What are the major differences between a leiomyoma and a leiomyosarcoma?

Answer 12

• leiomyoma: usually multiple masses, well-defined, white-whorled pattern of smooth muscle bundles, more common in reproductive age group
• leiomyosarcoma: usually a single mass, necrotic and hemorrhaging, more common in postmenopausal age group (leiomyosarcomas arise de novo)

Question 13

What is the pathophysiology behind dysmenorrhea? How do treat it?

Answer 13

• dysmenorrhea is largely a result of excessive eicosanoids (prostaglandins and related compounds), which occurs as a result of an excessive inflammatory response that occurs after ovulation in the endometrium; this leads to irregularly strong and painful contractions
• the main culprit is PGF2alpha (plays a major role in contracting uterine vessels, contracting uterine smooth muscle, and sensitizing endometrial nociceptors)
• (note that the anti-contracting prostacyclin is actually decreased in these patients!)
• treat with NSAIDs; OCPs also help by preventing ovulation and keeping the endometrial lining thin (lessens the inflammatory response)